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The “good death” Euthanasia means ‘the good death’ and “to euthanize” means to bring about a person’s death to relieve the person of a serious distress. Since, for most us, death is not something we welcome, the phrase “the good death” can seem almost self-contradictory. Yet, most of us know of people tormented by pain or disability, who find their lives so miserable that dying appears welcome. This is especially true where the persons involved are at the end of life.

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The “good death” How should we, as individuals, as professionals (nurses, doctors, hospital administrators), or policy-makers respond to these kinds of cases? The question becomes personal because any of us, at any time, might be in the situation where death is our best alternative. Should we embrace euthanasia? The answer is contentious for several reasons.

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Reasons for disagreement First, there is disagreement over whether it is ethical for a person to seek his own death to end some kind of misery. This is suicide and many people condemn it. Second, even where it is accepted that a person may seek his own death, disagreements exist over the ethically appropriate means and circumstances to achieve it. Third, there are cases where a person is incompetent to make a life or death decision for himself; others must make it for him, which creates still a third source of controversy: when, if ever, should an incompetent person be euthanized?

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Reasons for disagreement Underlying these disputes are differing perspectives on two issues: The moral meaning and relevance of the distinction between killing and letting die. The weight that should be given to personal autonomy in cases where a patient requests euthanasia.

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Killing and letting die To kill someone (including oneself) is to take a definite action to end his or her life (e.g., administering a lethal injection). To allow someone to die, by contrast, is to take no steps to prolong that person’s life when those steps seem called for—failing to give a needed injection of antibiotics, for example. This distinction is the basis for differentiating two forms of euthanasia, active and passive. Active euthanasia is killing a patient who requests to die. Passive euthanasia is allowing a patient to die who requests to die.

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Killing and letting die This distinction is used in most contemporary codes of medical ethics (e.g., the American Medical Association’s Code of Ethics) and is also recognized in the Anglo-American tradition of law. Except in special circumstances, it is illegal to deliberately cause the death of another person. It is not, however, illegal (except in special circumstances) to allow a person to die.

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Autonomy A second major issue fueling disputes over euthanasia is the extent to which personal autonomy should be allowed to enter into decisions to end a person’s life. Autonomy is the ability to act on decisions we have made and it is something most people highly value because it exercise is critical in allowing us to live the kind of life we find worthwhile. The idea of autonomy is also strongly associated with the idea that a person’s life is his own. That connection is perhaps most strongly felt in cases where people are suffering severe pain or disability, as in the Dax Cowart case (discussed in chapter 1).

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Autonomy In such cases it is natural to think: the lives of these people belong to them. Surely they should be the ones who should decide whether those lives should continue. Yet, there are those who disagree for a variety of reasons including:

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Autonomy “Your life” is really not yours but God’s so you have no business taking it. You do not necessarily know what’s in your best interests. Circumstances could improve. There could be deep value in your suffering that would be lost if you simply did what you wanted. You have obligations to others and can be valuable to others. These facts can provide powerful reasons for staying alive. Society, as an institution, has a deep interest in insisting on a basic attitude of respect for life. Allowing life and death decisions to rest on individual autonomy undermines that interest.

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Death isn’t what it used to be But adding to the complexity of the ethical issues surrounding euthanasia have been advances in medical technology over the past forty. For example, up until recently, the answer to the question of when you were dead was simple: you are dead when your heart stops beating. Not any more. The question “When is someone dead?” hardly seemed worth asking until the rise of intensive care medicine in the 1950s and the increasing success of organ transplantation in the 1970s. People began to ask:

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Death isn’t what it used to be “If a physician switches off the ventilator that is keeping a patient’s body supplied with oxygen, is this homicide?” “If a surgeon removes the heart from a breathing patient, has she killed him?” These questions became more than academic exercises for a few surgeons who were arrested and charged with homicide, and finding answers became more urgent for personal and practical reasons. If surgeons couldn’t remove organs from a body with a beating a heart without fearing a trial and a prison sentence, they would no longer perform transplants.

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Definition of death Discussions during the 1970s and 1980s about determining criteria for death led to the development of four basic ideas about what it means to be dead: 1. Cardiopulmonary. A person is dead when her heart stops beating and she is no longer breathing. (traditional definition of death) 2. Whole Brain. Death is “the irreversible cessation of all brain functions.” A person is dead when his brain displays no organized electrical activity and even the brain stem, which controls basic functions such as breathing and blood pressure, is electrically silent.

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Definition of death 3. Higher Brain. Death is the permanent loss of consciousness. An individual in an irreversible coma is dead, even though her brain stem continues to regulate her heartbeat and blood pressure. 4. Personhood. Death occurs when someone ceases to be a person. Relevant to deciding whether this has happened is information about the absence of mental activities such as reasoning, remembering, experiencing an emotion, anticipating the future, and interacting with others.

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Definition of death Legally, in the US, death is defined by the 1985 federal Universal Determination of Death Act which is based on criteria (1) and (2). A person is dead when either (1) or (2) is true. This definition is embodied in the laws of all fifty states. These changed definitions of death have become a critical part of the euthanasia debate in cases where a person has been kept “alive” on life-support technology. When, if ever is justifiable to take such individuals off life support, especially when they are not competent to give consent? The high profile court cases of Nancy Cruzan, Karen Quinlan, and Terri Schiavo, summarized in this chapter, highlight the moral relevance of the new definitions of death.

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Section 1: The Killing–Letting-Die Distinction In many contexts, killing and letting die is a simple and straightforward distinction. If I push a person’s head under water until he drowns, I have killed him. If a novice swimmer is floundering next to my boat and I can save him by tossing a nearby life preserver and don’t, I have allowed him to die. But, matters are not always so simple, particularly in the context of euthanasia. A distinction is sometimes drawn between active and passive euthanasia which rests on the killing- letting die distinction.

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Section 1: The Killing–Letting-Die Distinction In a classic example: if a doctor injects a patient with a fatal dose of morphine to relieve the suffering of the patient who wishes to die, the doctor has actively euthanized or killed the patient. In contrast, where a doctor removes some form of life support, at the patient’s request, and the patient dies, the doctor has passively euthanized the patient. The doctor has allowed the patient to die; he has not killed the patient.

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Section 1: The Killing–Letting-Die Distinction But as Rachels’ paper (“Active and Passive Euthanasia”) suggests, the distinction between doing and allowing depends on background conditions. He offers the example of insulting a person by not shaking their hand. You come to a party with three others: I shake their hands but I don’t shake yours. If criticized, I might say “I didn’t do anything!” but the reasonable reply is yes I did: I insulted him by not shaking his hand”.

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Section 1: The Killing–Letting-Die Distinction The hand-shaking example illustrates another feature of the debate over the killing-letting die distinction. In some instances at least, even if we agree that an action, A, is an instance of killing and another action, B, is an instance of letting die, it may be that from a moral point of view, there is no difference between A and B. A and B are equally right or equally wrong. The question of the moral equivalence of killing and letting die is taken up in this section by James Rachels (“Active and Passive Euthanasia”) and Winston Nesbitt (“Is Killing No Worse Than Letting Die?”)

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Reading: Active and Passive Euthanasia James Rachels James Rachels challenges both the use and the moral significance of the distinction between active and passive euthanasia. Rachels argues that since both forms of euthanasia result in the death of a person, active euthanasia ought to be preferred to passive. Active euthanasia is more humane because it allows suffering to be brought to a speedy end. Furthermore, Rachels claims, the distinction itself can be shown to be morally irrelevant. Is there, he asks, any genuine moral difference between drowning a child and merely watching a child drown and doing nothing to save it?

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Reading: Active and Passive Euthanasia James Rachels Finally, Rachels attempts to show that the bare fact that there is a difference between killing and letting die doesn’t make active euthanasia wrong. Killing of any kind is right and wrong depending on the intentions and circumstances in which it takes place; if the intentions and circumstances are of a certain kind, then active euthanasia can be morally right.

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Reading: Active and Passive Euthanasia James Rachels For these reasons, Rachels suggests that the approval given to the active–passive euthanasia distinction in the Code of Ethics of the American Medical Association is unwise. He encourages physicians to rely upon the distinction only to the extent that they are forced to do so by law but not to give it any significant moral weight. In particular, they should not make use of it when writing new policies or guidelines.

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Reading: Is Killing No Worse Than Letting Die? Winston Nesbitt Winston Nesbitt rejects the claim that there is no moral difference between killing and letting die. He holds that the pair of cases offered by Rachels (see previous article) to show that there is no difference, as well as the pair offered by Tooley described in the article, fail to demonstrate the claim. In both pairs, the agent is prepared to kill and fails to do so only because unexpected circumstances make it unnecessary. This feature, Nesbitt argues, makes both cases in each pair equally reprehensible. The examples used by Rachels and Tooley are flawed and cannot support the claim that because letting die is morally acceptable, so, too, is killing. Both, in their cases, are morally unacceptable.

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Sections 2 and 3: The Case for Allowing Euthanasia and Assisted Suicide The readings in these sections address a second general issue underlying the euthanasia debate: how much weight should autonomy have in decisions to end life? As noted earlier, we value autonomy highly and its value seems especially relevant in life or death decisions because, in such cases, it seems reasonable to say that a patient’s life is his, not somebody else’s. As a consequent, what the patient wants to do with his own life seems like an extremely relevant, if not decisive, consideration in deciding whether to honor his request to end his life.

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Sections 2 and 3: The Case for Allowing Euthanasia and Assisted Suicide The first two writers in these sections challenge this view. J. Gay-Williams in “The Wrongfulness of Euthanasia” adopts a natural law perspective (natural law theory is discussed in Part VI “Foundations of Bioethics”, at the end of the book.) According to this view, human beings have a variety of natural goals or inclinations. These goals and inclinations represent standards of morality against which we can judge human behavior.

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Sections 2 and 3: The Case for Allowing Euthanasia and Assisted Suicide Humans are capable of acting against these goals. When they do, they are acting contrary to the moral standards that are part of nature. In such instances they are acting immorally. One important natural goal is to continue living. Since euthanasia involves ending life (one self’s or someone else’s) it violates this goal and so is morally wrong. On this view, personal autonomy has no moral weight in decisions about euthanasia.

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Sections 2 and 3: The Case for Allowing Euthanasia and Assisted Suicide Daniel Callahan in “When Self-Determination Runs Amok” contends there are considerations relevant to life and death decisions that severely limit the weight that autonomy should play in those decisions. Among these are the following: There exists long-standing societal goal of reducing the killing of one person by another, which endorsement of euthanasia would clearly violate. There also exists a common good, embodied in our public institutions, such as medicine, which represents more than simply an aggregate of the interests of individuals.

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Sections 2 and 3: The Case for Allowing Euthanasia and Assisted Suicide The autonomy argument for euthanasia wrongly implies that individuals may “in the name of their own private, idiosyncratic view of the good life” demand support from this common good. In particular, the autonomy argument suggests that the practice of medicine, whose long-standing purpose has been to preserve life, can be legitimately commandeered to end it. The papers by John Lachs (“When Abstract Moralizing Runs Amok”) and Peter Singer (“Voluntary Euthanasia: A Utilitarian Perspective”), in contrast, offer a defense of the relevance of autonomy to euthanasia decisions.

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Reading: The Wrongfulness of Euthanasia J. Gay-Williams J. Gay-Williams defines euthanasia as intentionally taking the life of a person who is believed to be suffering from some illness or injury from which recovery cannot reasonably be expected. Gay-Williams rejects passive euthanasia as a name for actions that are usually designated by the phrase but seems to approve of the actions themselves. He argues that euthanasia as intentional killing goes against natural law because it violates the natural inclination to preserve life. Furthermore, both self-interest and possible practical consequences of euthanasia provide reasons for rejecting it.

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Reading: When Self-Determination Runs Amok Daniel Callahan Daniel Callahan argues against any social policy allowing voluntary euthanasia and assisted suicide. He maintains that self-determination and mercy (the two values supporting them) may become separated. When this happens, assisted suicide for any reason and nonvoluntary euthanasia for the incompetent will become acceptable. Callahan rejects Rachels’ claim that the difference between killing and letting die is morally irrelevant.

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Reading: When Self-Determination Runs Amok Daniel Callahan He holds that the difference is fundamental and that the decision to terminate a life requires a judgment about meaning and quality that physicians are not competent to make. In general, Callahan warns us, we must not allow physicians to move beyond the bounds of promoting health, and exercise the power of deciding questions about human happiness and wellbeing. Permitting them to make such decisions will lead to widespread abuse and destroy the integrity of the medical profession.

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Reading: When Abstract Moralizing Runs Amok John Lachs John Lachs claims that Callahan fails to grasp the moral problems leading people to consider euthanasia. They are not interested in it as an escape from the suffering inherent in “the human condition,” but as an end to pain and a burdensome life. Callahan holds that even if we have the right to kill ourselves, it intrinsically cannot be transferred to others. But Lachs argues that the idea of a right that cannot be transferred makes no sense.

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Reading: When Abstract Moralizing Runs Amok John Lachs Callahan also claims that once the principle of taking life has been “legitimized,” there can be no good moral reasons for not killing someone for any reason at all. Lachs argues that Callahan’s claim rests on the view that judgments about our suffering and the value of our lives are subjective (and so not necessarily shared by others). Yet physicians are able to review objectively a patient’s request to die with respect to the patient’s condition and situation.

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Reading: When Abstract Moralizing Runs Amok John Lachs Contrary to Callahan’s implication, no one has ever endorsed the principle of autonomy as absolute. It expresses one value among others. But it recognizes that our lives belong to ourselves and that society must justify infringements, and this is what the debate over euthanasia is about.

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Reading: Voluntary Euthanasia: A Utilitarian Perspective Peter Singer Singer asks what makes it wrong, from a nonreligious view, to kill any being, including a human. The utilitarian answer, which he accepts, is that killing ends the possibility that the being can experience whatever further good life holds. For a “hedonistic utilitarian” this means happiness, and for a “preference utilitarian” it means the satisfaction of preferences. Thus, when unhappiness or the frustration of preferences outweighs life’s positive elements, killing is preferable to not killing. Singer addresses only voluntary euthanasia (including assisted suicide) and accepts Mill’s view that individuals are the best judges of their own interests and should be allowed to decide when the good things of life are outweighed by the bad, making death desirable.

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Reading: Voluntary Euthanasia: A Utilitarian Perspective Peter Singer He argues that the right to life should be viewed as an option, not as inalienable, which would make life a duty. It is necessary to determine that candidates for voluntary euthanasia are competent to make decisions and have access to palliative care, but in some instances even depressed people may be acceptable candidates. Finally, Singer asks whether allowing voluntary euthanasia would lead to the deaths of vulnerable individuals pressured into consenting to involuntary killing, then points to studies in the Netherlands and Oregon showing that the evidence does not support this view. He concludes that the utilitarian case for allowing patients to choose euthanasia is strong.

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Section 4: Deciding for the Incompetent In many cases of where euthanasia might be considered, the patient is unquestionably alive and capable making an autonomous decision and the moral question, as explored in sections 1-3, is whether it is ethically acceptable to end the patient’s life at his request. The court decision in the case of Karen Quinlan, discussed here, looks at questions that arise when the patient is incapable of exercising autonomy and so is incompetent to even make a request to die. In particular, it examines the legitimacy of having others make the decision to end a person’s life for that person.

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Reading: In the Matter of Karen Quinlan, an Alleged Incompetent Supreme Court of New Jersey The 1976 decision of the New Jersey Supreme Court in the case of Karen Quinlan was significant in establishing that a legally based right of privacy permits a patient to decide to refuse medical treatment. The court also held that this right can be exercised by a parent or guardian when the patient herself is in no position to do so. Thus, in the opinion of the court removal of life-sustaining equipment would not be a case of homicide (or any other kind of wrongful killing), even if the patient should die as a result.

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Reading: In the Matter of Karen Quinlan, an Alleged Incompetent Supreme Court of New Jersey The ruling in the Quinlan case has had an enormous impact on decisions about discontinuing extraordinary medical measures. However, the ruling has generally been construed rather narrowly so as to apply only to mentally incompetent patients who are brain dead, comatose, or in an irreversible coma.